Heart Disease and Stroke Statistics—2017 Update

Current State of Cardiovascular Health in the United States: What’s New? (Chapter 2)

• The AHA developed a Health Campaign for Life’s Simple 7, which emphasizes that adults and young people can live healthier lives by avoiding smoking and tobacco products, engaging in daily PA, eating a healthy diet, maintaining a healthy weight, and keeping cholesterol, BP, and glucose at healthy levels. New highlights from the cardiovascular health section include the following:

• A recent meta-analysis of 9 prospective cohort studies involving 12 878 participants contributed new estimates of the importance of cardiovascular health metrics and risk for clinical events. The meta-analysis showed that achieving the greatest ideal cardiovascular health metrics was associated with a lower risk of stroke (relative risk, 0.31; 95% confidence interval [CI], 0.25–0.38), CVD (relative risk, 0.20; 95% CI, 0.11–0.37), cardiovascular mortality (relative risk, 0.25; 95% CI, 0.10–0.63), and all-cause mortality (relative risk, 0.55; 95% CI, 0.37–0.80).

• The health benefits of pursuing cardiovascular health are observed across races/ethnicities and the nation. New data on measures of cardiovascular health in Hispanics find similar results as previous reports in non-Hispanic groups. Studies from non-US populations also support the importance of Life’s Simple 7 on future disease prevention.

• Trends in improvements in overall cardiovascular health metrics are projected to reduce coronary heart disease deaths by 30% between 2010 and 2020.

• The current evidence supports a range of complementary life course strategies to improve cardiovascular health in youth and adults as they age. Such approaches focus on both (1) improving cardiovascular health among those who currently have less than optimal levels and (2) preserving cardiovascular health among those who currently have ideal levels. The AHA and the literature support the importance of the following:

• Individual-focused approaches, which target lifestyle and risk factor treatments at the individual level.

• Healthcare systems approaches, which encourage, facilitate, and reward efforts by providers and patients to improve health behaviors and health factors.

• Population approaches, which target lifestyle and treatments in schools, places of worship, work-places, local communities, and states, as well as throughout the nation.

Smoking and Tobacco Use (Chapter 3)

• In 2015, among adults ≥18 years of age, overall rates of tobacco use were estimated to be 15.2% (16.7% of males and 13.7% of females; National Health Interview Survey).

• In the US, substantially higher tobacco use rates are found in low socioeconomic status, Native American, and lesbian, gay, bisexual, or transgender people reporting disability or activity limitations, as well as mentally ill populations. There also is substantial regional variation in the percentage of current smokers.

  • The region with the highest rates is the Midwest (20.7%), and the state with the highest percentage was West Virginia (26.7%). The lowest percentages regionally were observed in the West (13.1%), and by state in Utah (9.7%).

• In 2015, e-cigarettes were the most commonly used tobacco product among middle school (5.3%) and high school (16.0%) students. The risks for nicotine dependence and for CVD associated with regular e-cigarette use are unknown. Use of cigarillos or other mass marketed cigars, hookahs, and water pipes has also become increasingly common in the past few years.

• In May 2016, the US Food and Drug Administration placed e-cigarettes under the same regulations and restrictions as traditional combustible cigarettes. Furthermore, Tobacco 21 legislation, which mandates a minimum age of 21 years to purchase tobacco, is becoming increasingly common in the United States.

Physical Inactivity (Chapter 4)

• More Americans are meeting the federal PA guidelines. The age-adjusted percentage of US adults (≥18 years) who met both the muscle-strengthening and aerobic guidelines increased from 14.3% in 1998 to 21.6% in 2015. The percentage of US adults who met the aerobic guideline increased from 40.0% in 1998 to 49.8% in 2015.

• In 2015, only 27.1% of high school students met activity recommendations of ≥60 minutes of PA on all 7 days of the week, and 14.3% of high school students reported that they were inactive on all of the previous 7 days.

• Even low levels of leisure time PA (up to 75 minutes of brisk walking per week) were associated with reduced risk of mortality compared with participants who engaged in no PA.

• A study of American adults reported that inadequate levels of aerobic PA (after adjustment for body mass index) were associated with an estimated 11.1% of aggregate healthcare expenditures.

Nutrition (Chapter 5)

• The 2015 US Dietary Guidelines Advisory Committee recently concluded that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low-fat or nonfat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat; and low in sugar-sweetened foods and drinks and refined grains.

• Between 2003 to 2004 and 2011 to 2012 in the United States, the mean AHA healthy diet score improved in both children and adults. The prevalence of an ideal healthy diet score (>80) increased from 0.2% to 0.6% in children and from 0.7% to 1.5% in adults. The prevalence of an intermediate healthy diet score (40–79) increased from 30.6% to 44.7% in children and from 49.0% to 57.5% in adults. These improvements were largely attributable to increased whole grain consumption and decreased sugar-sweetened beverage consumption in both children and adults.

• Between 1999 and 2012, although AHA healthy diet scores tended to improve in all race/ethnicity, income, and education levels, many disparities present in earlier years widened over time, with generally smaller improvements seen in minority groups and those with lower income or education.

Overweight and Obesity (Chapter 6)

• The prevalence of obesity among adults and youth in the United States increased significantly from 1999 to 2000 through 2013 to 2014. However, the increase in obesity prevalence began to level off and was not statistically significant for adults from the time period 2003 to 2004 through 2011 to 2012 and for youth from the time period 2003 to 2004 through 2013 to 2014.

• Body mass index and waist circumference cut points in US guidelines underestimate obesity and CVD risk in Asian and South Asian populations.

• Definitions of “metabolically healthy obesity” vary, and over time, a substantial proportion of those with metabolically healthy obesity transition to metabolically unhealthy. The risk of CVD events, particularly HF, may be increased with obesity even in the absence of metabolic risk factors.

Family History and Genetics (Chapter 7)

• Among adults ≥20 years of age, 12.2% reported having a parent or sibling with a heart attack or angina before age 50 years, with the highest sex-specific prevalence observed among non-Hispanic white males and females.

High Blood Cholesterol and Other Lipids (Chapter 8)

• Mean low-density lipoprotein cholesterol decreased from 126 mg/dL in 1999 to 2000 to 111 mg/dL in 2013 to 2014 among US adults. The age-adjusted prevalence of high low-density lipoprotein cholesterol decreased from 42.9% in 1999 to 2000 to 28.5% in 2013 to 2014.

• Data from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000 to NHANES 2011 to 2012 show that the use of cholesterol-lowering treatment has increased substantially among adults, from 8% in 1999 to 2000 to 18% in 2011 to 2012. During this period, the use of statins increased from 7% to 17%.

• From 1988 to 1994 to 2013 to 2014, mean serum total cholesterol for adolescents 12 to 19 years of age has decreased across all subgroups of race and sex.

High Blood Pressure (Chapter 9)

• The age-adjusted prevalence of hypertension among US adults ≥20 years of age is estimated to be 34.0% in NHANES 2011 to 2014, which is equivalent to 85.7 million adults.

• The prevalence of high BP or borderline high BP among US children and adolescents 8 to 17 years old is 11%.

• The SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated lower CVD and mortality risk with a systolic BP target goal of 120 mm Hg versus 140 mm Hg. It is estimated that 16.8 million US adults meet the SPRINT eligibility criteria.

• The prevalence of apparent treatment-resistant hypertension was estimated from a meta-analysis to be 13.7%.

• Controlling hypertension in all patients with CVD and stage 2 hypertension could be cost-saving.

Diabetes Mellitus (Chapter 10)

• An estimated 23.4 million adults have diagnosed diabetes mellitus (DM), 7.6 million have undiagnosed DM, and 81.6 million have prediabetes.

• Analyses of high school–aged blood donors in 2011 to 2012 reported that 10% had prediabetes hemoglobin A1c levels and an additional 0.6% had hemoglobin A1c ≥6.5%, the threshold endorsed to diagnose DM.

• A recent large meta-analysis of randomized controlled trials showed that exercise may exert its favorable effects by significantly improving glucose tolerance and insulin resistance. The benefits of exercise were further supported by a large intervention project that showed that higher fitness was associated with a lower risk of incident DM regardless of demographic characteristics and baseline risk factors.

• In 2014, there were 76 488 DM-related deaths.

Metabolic Syndrome (Chapter 11)

• The prevalence of metabolic syndrome in youth ages 12 to 19 years old has decreased in NHANES 2009 to 2010 and 2011 to 2012. This important epidemiological statistic mirrors a previously documented plateau and decrease in the prevalence of metabolic syndrome in adults.

• The decrease in metabolic syndrome in youth most closely correlates with rising high-density lipoprotein cholesterol and lowered triglyceride levels, which are potentially driven by decreased carbohydrate intake and increased unsaturated fat intake.

• Despite these encouraging findings, recent data have confirmed that the severity of existing metabolic syndrome progresses with advancing age in approximately three quarters (76%) of adults, with faster progression of metabolic syndrome noted in women and younger people.

Chronic Kidney Disease (Chapter 12)

• The total prevalence of chronic kidney disease is rising globally, primarily because of aging populations. The Global Burden of Disease study estimates that kidney disease is now the 19th-leading cause of death, up from the 36th-leading cause of death in 1990.

• According to recent figures from the United States Renal Data System, the number of people with prevalent end-stage renal disease is increasing, with 661 648 prevalent cases as of December 31, 2013. However, the incidence rate has declined; 117 162 new cases were reported in 2013.

• The prevalence of chronic kidney disease in adults ≥30 years of age is projected to increase to 14.4% in 2020 and 16.7% in 2030.

• Cardiovascular risk in patients with kidney disease can now be classified as high, intermediate, and low according to estimated glomerular filtration rate and albuminuria categories defined by the Kidney Disease Improving Global Outcomes (KDIGO) working group.

Total Cardiovascular Diseases (Chapter 13)

• An estimated 92.1 million US adults have at least 1 type of CVD. By 2030, 43.9% of the US adult population is projected to have some form of CVD.

• From 2004 to 2014, death rates attributable to CVD declined 25.3%. The actual number of CVD deaths decreased 6.7%.

• Globally, 80% of CVD deaths take place in low- and middle-income countries and occur almost equally in males and females.

Stroke and Cerebrovascular Disease (Chapter 14)

• When considered separately from other CVDs, stroke ranks No. 5 among all causes of death, behind diseases of the heart, cancer, chronic lower respiratory disease, and unintentional injuries/accidents.

• Globally, in 2013 there were 6.5 million stroke deaths, making stroke the second-leading cause of death behind ischemic heart disease.

• Approximately 795 000 strokes occur in the United States each year. On average, every 40 seconds, someone in the United States has a stroke, and on average, every 4 minutes, someone dies of a stroke.

• Approximately 60% of stroke deaths occurred outside of an acute care hospital.

• A review of recent clinical trials identified the benefit of intense BP reduction, which reduced risks of stroke outcomes.

• Adherence to a Mediterranean-style diet that was higher in nuts and olive oil was associated with a reduced risk of stroke.

• One year after stroke, blacks were less likely to report independence in activities of daily living and instrumental activities of daily living than whites.

Global Cardiovascular Disease (Chapter 15)

• In 2013, the highest prevalence of ischemic stroke (1015 to 1184 cases per 100 000 people) was in high-income countries (particularly in the United States), with the lowest (up to 339 per 100 000) in low- and middle-income countries.

• CVD was the most common underlying cause of death in the world in 2013, accounting for an estimated 17.3 million (95% uncertainty interval, 16.5–18.1 million) of 54 million total deaths, or 31.5% (95% uncertainty interval, 30.3%–32.9%) of all global deaths.

• Cost-effective medications such as aspirin, statins, and BP-lowering agents remain unaffordable for much of the world. New community health worker-based strategies to improve their delivery are proving to be highly effective.

Congenital Cardiovascular Defects and Kawasaki Disease (Chapter 16)

• The mortality attributed to congenital cardiovascular defects decreases with later gestational age (to 40 weeks), which suggests early delivery will not benefit most patients with congenital cardiovascular defects.

• Health outcomes are improving for congenital cardiovascular defects, and survival is increasing, leading to a population shift toward adulthood.

• The rising population of adults with congenital heart disease adds to management complexity and emphasizes the need for coordinated care by adult congenital cardiovascular specialists.

Disorders of Heart Rhythm (Chapter 17)

• The frequency and adverse consequences of clinically unrecognized and asymptomatic atrial fibrillation (AF) are increasingly reported, particularly in older adults. For instance, in a community-based study in Sweden, >7000 people 75 to 76 years of age were monitored intermittently; 3% had newly diagnosed AF, of whom only 17% had their AF detected by a screening ECG.

• A recent meta-analysis from 4 large contemporary randomized trials revealed that AF is associated with systemic embolism, occurring at a rate of 0.24 per 100-person years compared with 1.92 for stroke per 100-person years.

• Data from the Framingham Heart Study, the Atherosclerosis Risk in Communities study, the United Kingdom, and other sites suggest that the incidence and prevalence of AF are increasing over time.

Sudden Cardiac Arrest (Chapter 18)

• In the 2015 CARES (Cardiac Arrest Registry to Enhance Survival) National Survival Report for emergency medical services–treated nontraumatic cardiac arrest, the survival rate to hospital discharge was 10.6% for adults >18 years old, 23.5% for children 13 to 18 years old, 16.6% for children >1 to 12 years old, and 6.2% for children <1 year old.

• In 2015, Get With the Guidelines–Resuscitation reported the rate of survival to hospital discharge from pulseless in-hospital cardiac arrest in adults ≥18 years old was 23.8% (95% CI, 23.2%–24.3%], whereas in children 0 to 18 years old, it was 35.9% (95% CI, 31.4%–40.6%), and in neonates (0–30 days old), it was 24.2% (95% CI, 18.2%–31.4%).

Subclinical Atherosclerosis (Chapter 19)

• Subclinical CVD is common among US adults living in rural areas; a study from central Appalachia reported 56% of participants had coronary artery calcium scores >0.

• Coronary artery calcium scores >400 versus 0 are associated with an increased risk for cancer, chronic kidney disease, pneumonia, chronic obstructive pulmonary disease, and hip fracture.

• Conflicting data have been reported on the contribution of carotid intima-media thickness to risk prediction. A recent study from a consortium of 14 population-based cohorts demonstrated little additive value of common carotid intima-media thickness to Framingham Risk Score for purposes of discrimination and reclassification as far as incident myocardial infarction (MI) and stroke were concerned. However, for those at intermediate risk, the addition of mean common carotid intimamedia thickness to an existing cardiovascular risk score resulted in a small but statistically significant improvement in risk prediction.

Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris (Chapter 20)

• A majority of MIs occur during a hospitalization for another reason, rather than being the cause of hospitalization.

• Silent MIs (ie, MIs detected on ECG without a definite or probable hospitalized MI) account for almost 50% of incident MIs.

• The percentage of US adults with a 10-year predicted CVD risk ≥20% decreased from 13.0% in 1999 to 2000 to 9.4% in 2011 to 2012.

• Among US males and females <55 years old, coronary heart disease mortality did not decline between 1990 to 1999 and 2000 to 2011.

• Between 2001 to 2003 and 2007 to 2009, age-adjusted mortality after MI decreased among white males, but no changes were present for white females or black males or females.

Cardiomyopathy and Heart Failure (Chapter 21)

• HF prevalence has increased from 5.7 million (2009 to 2012) to 6.5 million (2011 to 2014) in Americans ≥20 years of age.

• Five-year survival of HF diagnosis after an MI has also improved in 2001 to 2010 versus 1990 to 2000, from 54% to 61%.

• Greater adherence to the AHA’s Life Simple 7 guidelines (better profiles in smoking, body mass index, PA, diet, cholesterol, BP, and glucose) is associated with a lower lifetime risk of HF and better cardiac structure and functional parameters by echocardiography.

• Of incident hospitalized HF events, 53% had HF with reduced ejection fraction and 47% had preserved ejection fraction. Black males had the highest proportion of hospitalized HF with reduced ejection fraction (70%); white females had the highest proportion of hospitalized HF with preserved ejection fraction (59%).

Valvular Diseases (Chapter 22)

• Although rheumatic heart disease is uncommon in high-income countries such as the United States, it remains an important cause of morbidity and mortality in low- and middle-income countries.

• Both administrative and community-based data report that the incidence of infective endocarditis did not change after the publication of the 2007 AHA guidelines for management of infective endocarditis, ² which restricted the indications for antibiotic prophylaxis before dental procedures.

• From the time of initial US Food and Drug Administration approval in late 2011 through 2014, more than 26 000 transcatheter aortic valve replacements were performed at 348 centers in 48 states in the United States. Two thirds of these patients were >80 years of age.

Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism), Chronic Venous Insufficiency, Pulmonary Hypertension (Chapter 23)

Peripheral Artery Disease and Aortic Diseases (Chapter 24)

• From 2003 to 2011, there was a significant increase in endovascular treatment of critical limb ischemia (from 5.1% to 11.0%), which was accompanied by lower rates of in-hospital mortality and major amputation, as well as shorter hospital length of stay.

• Endovascular repair may yield better outcomes in the first few years, but after 8 years of follow-up in one study, the open repair group and the endovascular repair group demonstrated similar survival. Of note, individuals in the endovascular repair group had a higher rate of eventual aneurysm rupture (5.4%) than patients who underwent open repair (1.4%).

Quality of Care (Chapter 25)

• Overall, inpatient quality of care for patients with acute coronary syndromes, HF, and stroke continues to show gains, with compliance rates above 95% for some measures.

• Although performance on inpatient quality-of-care measures or quality-of-care measures at discharge in patients after MI or stroke remains high (>90% for most measures), performance on outpatient quality-of-care measures, especially those that pertain to body mass index assessment and PA assessment in the outpatient setting, remains low.

• Overall rates of bystander cardiopulmonary resuscitation remain low.

Medical Procedures (Chapter 26)

• In 2015, 2804 heart transplantations were performed in the United States, the most ever.

Economic Cost of Cardiovascular Disease (Chapter 27)

• CVD and stroke accounted for 14% of total health expenditures in 2012 to 2013, more than any major diagnostic group.

• The annual direct and indirect cost of CVD and stroke in the United States was an estimated $316.1 billion in 2012 to 2013. This figure includes $189.7 billion in expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medication, and home health care, but not the cost of nursing home care) and $126.4 billion (indirect costs) in lost future productivity attributed to premature CVD and stroke mortality in 2012 to 2013.

• Taking into account nursing home care costs, the total direct medical costs of CVD between 2012 to 2030 are projected to increase from $396 billion to $918 billion.

Disease Prevalence

Prevalence is an estimate of how many people have a condition at a given point or period in time. The NCHS/CDC conducts health examination and health interview surveys that provide estimates of the prevalence of diseases and risk factors. In this Update, the health interview part of the NHANES is used for the prevalence of CVDs. NHANES is used more than the NHIS because in NHANES, AP is based on the Rose Questionnaire; estimates are made regularly for HF; hypertension is based on BP measurements and interviews; and an estimate can be made for total CVD, which includes MI, AP, HF, stroke, and hypertension.

A major emphasis of this Statistical Update is to present the latest estimates of the number of people in the United States who have specific conditions, to provide a realistic estimate of burden. Most estimates based on NHANES prevalence rates are based on data collected from 2011 to 2014 (in most cases, these are the latest published figures). These are applied to census population estimates for 2014. Differences in population estimates cannot be used to evaluate possible trends in prevalence because these estimates are based on extrapolations of rates beyond the data collection period by use of more recent census population estimates. Trends can only be evaluated by comparing prevalence rates estimated from surveys conducted in different years.

Risk Factor Prevalence

The NHANES 2011 to 2014 data are used in this Update to present estimates of the percentage of people with high lipid values, DM, overweight, and obesity. The NHIS is used for the prevalence of cigarette smoking and physical inactivity. Data for students in grades 9 through 12 are obtained from the YRBSS.

Incidence and Recurrent Attacks

An incidence rate refers to the number of new cases of a disease that develop in a population per unit of time. The unit of time for incidence is not necessarily 1 year, although incidence is often discussed in terms of 1 year. For some statistics, new and recurrent attacks or cases are combined. Our national incidence estimates for the various types of CVD are extrapolations to the US population from the FHS, the ARIC study, and the CHS, all conducted by the NHLBI, as well as the GCNKSS, which is funded by the NINDS. The rates change only when new data are available; they are not computed annually. Do not compare the incidence or the rates with those in past editions of the Heart Disease and Stroke Statistics Update (also known as the Heart and Stroke Statistical Update for editions before 2005). Doing so can lead to serious misinterpretation of time trends.

Mortality

Mortality data are generally presented according to the underlying cause of death. “Any-mention” mortality means that the condition was nominally selected as the underlying cause or was otherwise mentioned on the death certificate. For many deaths classified as attributable to CVD, selection of the single most likely underlying cause can be difficult when several major comorbidities are present, as is often the case in the elderly population. It is useful, therefore, to know the extent of mortality attributable to a given cause regardless of whether it is the underlying cause or a contributing cause (ie, the “any-mention” status). The number of deaths in 2014 with any mention of specific causes of death was tabulated by the NHLBI from the NCHS public-use electronic files on mortality.

The first set of statistics for each disease in this Update includes the number of deaths for which the disease is the underlying cause. Two exceptions are Chapter 9 (High Blood Pressure) and Chapter 20 (Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris). HBP, or hypertension, increases the mortality risks of CVD and other diseases, and HF should be selected as an underlying cause only when the true underlying cause is not known. In this Update, hypertension and HF death rates are presented in 2 ways: (1) As nominally classified as the underlying cause and (2) as any-mention mortality.

National and state mortality data presented according to the underlying cause of death were computed from the mortality tables of the NCHS/CDC World Wide Web site or the CDC compressed mortality file. Any-mention numbers of deaths were tabulated from the electronic mortality files of the NCHS/CDC World Wide Web site.

Population Estimates

In this publication, we have used national population estimates from the US Census Bureau for 2014¹ in the computation of morbidity data. NCHS/CDC population estimates² for 2014 were used in the computation of death rate data. The Census Bureau World Wide Web site contains these data, as well as information on the file layout.

Hospital Discharges and Ambulatory Care Visits

Estimates of the numbers of hospital discharges and numbers of procedures performed are for inpatients discharged from short-stay hospitals. Discharges include those discharged alive, dead, or with unknown status. Unless otherwise specified, discharges are listed according to the first-listed (primary) diagnosis, and procedures are listed according to all listed procedures (primary plus secondary). These estimates are from the NHDS of the NCHS/CDC unless otherwise noted. Ambulatory care visit data include patient visits to physician offices and hospital outpatient departments and EDs. Ambulatory care visit data reflect the first-listed (primary) diagnosis. These estimates are from the NAMCS and NHAMCS of the NCHS/CDC. Data for community health centers, which were included in estimates in previous years, were not available for 2012 NAMCS estimates included in this Update.

International Classification of Diseases

Morbidity (illness) and mortality (death) data in the United States have a standard classification system: the ICD. Approximately every 10 to 20 years, the ICD codes are revised to reflect changes over time in medical technology, diagnosis, or terminology. Where necessary for comparability of mortality trends across the 9th and 10th ICD revisions, comparability ratios computed by the NCHS/CDC are applied as noted.³ Effective with mortality data for 1999, we are using the 10th revision (ICD-10).⁴ It will be a few more years before the 10th revision is systematically used for hospital discharge data and ambulatory care visit data, which are based on ICD-9-CM.⁵

Age Adjustment

Prevalence and mortality estimates for the United States or individual states comparing demographic groups or estimates over time are either age specific or age adjusted to the 2000 standard population by the direct method.⁶ International mortality data are age adjusted to the European standard.⁷ Unless otherwise stated, all death rates in this publication are age adjusted and are deaths per 100 000 population.

Data Years for National Estimates

In this Update, we estimate the annual number of new (incidence) and recurrent cases of a disease in the United States by extrapolating to the US population in 2013 from rates reported in a community- or hospital-based study or multiple studies. Age-adjusted incidence rates by sex and race are also given in this report as observed in the study or studies. For US mortality, most numbers and rates are for 2014. For disease and risk factor prevalence, most rates in this report are calculated from the 2011 to 2014 NHANES. Because NHANES is conducted only in the noninstitutionalized population, we extrapolated the rates to the total US population in 2014, recognizing that this probably underestimates the total prevalence, given the relatively high prevalence in the institutionalized population. The numbers and rates of hospital inpatient discharges for the United States are for 2010. Numbers of visits to physician offices and hospital EDs are for 2012, whereas hospital outpatient department visits are for 2011. Except as noted, economic cost estimates are for 2012 to 2013.

Cardiovascular Disease

For data on hospitalizations, physician office visits, and mortality, CVD is defined according to ICD codes given in Chapter 13 of the present document. This definition includes all diseases of the circulatory system, as well as congenital CVD. Unless otherwise specified, an estimate for total CVD does not include congenital CVD. Prevalence of CVD includes people with hypertension, HD, stroke, PAD, and diseases of the veins.

Race/Ethnicity

Data published by governmental agencies for some racial groups are considered unreliable because of the small sample size in the studies. Because we try to provide data for as many racial and ethnic groups as possible, we show these data for informational and comparative purposes.

Relevance of Ideal Cardiovascular Health

• Since the AHA announced its 2020 Impact Goals, multiple independent investigations have confirmed the importance of these metrics and the concept of cardiovascular health. Findings include strong inverse, stepwise associations in the United States of the metrics and cardiovascular health with all-cause mortality, CVD mortality, and HF; with preclinical measures of atherosclerosis such as carotid IMT arterial stiffness, and coronary artery calcium prevalence and progression; with physical functional impairment and frailty⁴; and with cognitive decline and depression. ^5,6 Similar relationships have also been seen in non-US populations.^5,7–10

• A recent study in a large Hispanic/Latino cohort study in the United States found that associations of CVD and cardiovascular health metrics compared favorably with existing national estimates; however, some of the associations varied by sex and heritage, providing important information to guide targeted health promotion efforts toward achieving 2020 goals.¹¹

• Ideal health behaviors and ideal health factors are each independently associated with lower CVD risk in a stepwise fashion (Chart 2-1). In other words, across any level of health behaviors, health factors are associated with incident CVD; conversely, across any level of health factors, health behaviors are still associated with incident CVD.¹²

• In addition, only modest intercorrelations are apparent between different cardiovascular health metrics. On the basis of NHANES 1999 to 2002, these ranged from a correlation of −0.12 between PA and HbA1c to a correlation of 0.29 between BMI and HbA1c. Thus, substantial independent variation in each cardiovascular health component exists, and each is independently related to cardiovascular outcomes.¹³

• These findings corroborate the independent value of targeting each of these 7 metrics as separate aims.

• Analyses from the US Burden of Disease Collaborators demonstrated that each of the 7 health factors and behaviors caused substantial mortality and morbidity in the United States in 2010. The top risk factor related to overall disease burden was suboptimal diet, followed by tobacco smoking, high BMI, raised BP, high fasting plasma glucose, and physical inactivity.¹⁴

• A stepwise association was present between the number of ideal cardiovascular health metrics and risk of death based on NHANES 1988 to 2006 data.¹⁵ The HRs for people with 6 or 7 ideal health metrics compared with 0 ideal health metrics were 0.49 (95% CI, 0.33–0.74) for all-cause mortality, 0.24 (95% CI, 0.13–0.47) for CVD mortality, and 0.30 (95% CI, 0.13–0.68) for IHD mortality.¹⁵ Ford et al¹³ demonstrated similar relationships.

• A recent meta-analysis of 9 prospective cohort studies involving 12 878 participants reported that achieving the most ideal cardiovascular health metrics was associated with lower risk of all-cause mortality (RR, 0.55; 95% CI, 0.37–0.80), cardiovascular mortality (RR, 0.25; 95% CI, 0.10–0.63), CVD (RR, 0.20; 95% CI, 0.11–0.37), and stroke (RR, 0.31; 95% CI, 0.25–0.38).¹⁶

• The adjusted population attributable fractions for CVD mortality were as follows¹⁵:

  • 40.6% (95% CI, 24.5%–54.6%) for HBP

  • 13.7% (95% CI, 4.8%–22.3%) for smoking

  • 13.2% (95% CI, 3.5%–29.2%) for poor diet

  • 11.9% (95% CI, 1.3%–22.3%) for insufficient PA

  • 8.8% (95% CI, 2.1%–15.4%) for abnormal glucose levels

• The adjusted population attributable fractions for IHD mortality were as follows¹⁵:

  • 34.7% (95% CI, 6.6%–57.7%) for HBP

  • 16.7% (95% CI, 6.4%–26.6%) for smoking

  • 20.6% (95% CI, 1.2%–38.6%) for poor diet

  • 7.8% (95% CI, 0%–22.2%) for insufficient PA

  • 7.5% (95% CI, 3.0%–14.7%) for abnormal glucose levels

• Data from the REGARDS cohort also demonstrated a stepwise association between cardiovascular health metrics and incident stroke. Using a cardiovascular health score scale ranging from 0 to 14, every unit increase in cardiovascular health was associated with an 8% lower risk of incident stroke (HR, 0.92; 95% CI, 0.88–0.95), with a similar effect size for white (HR, 0.91; 95% CI, 0.86–0.96) and black (HR, 0.93; 95% CI, 0.87–0.98) participants.¹⁷

• The Cardiovascular Lifetime Risk Pooling Project showed that adults with all-optimal risk factor levels (similar to having ideal cardiovascular health factor levels of cholesterol, blood sugar, and BP, as well as nonsmoking) have substantially longer overall and CVD-free survival than those who have poor levels of ≥1 of these cardiovascular health factor metrics. For example, at an index age of 45 years, males with optimal risk factor profiles lived on average 14 years longer free of all CVD events, and 12 years longer overall, than people with ≥2 risk factors.¹⁸

• Better cardiovascular health is associated with less incident HF,¹⁹ less subclinical vascular disease,^20,21 better global cognitive performance and cognitive function,^22,23 lower prevalence²⁴ and incidence²⁵ of depressive symptoms, and lower loss of physical functional status.²⁶

• The AHA’s 2020 Strategic Impact Goals are to improve cardiovascular health among all Americans. On the basis of NHANES 1999 to 2006, several social risk factors (low family income, low education level, minority race, and single-living status) were related to lower likelihood of attaining better cardiovascular health as measured by Life’s Simple 7 scores.²⁷

Cardiovascular Health: Current Prevalence

(See Table 2-2 and Charts 2-2 through 2-10)

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Chart 2-2

Prevalence (unadjusted) estimates of poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals, among US children aged 12 to 19 years

*Healthy Diet Score reflects 2011 to 2012 NHANES.

Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2013 to 2014.

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Chart 2-10

Age-standardized cardiovascular health status by US states, BRFSS, 2009

A, Age-standardized prevalence of population with ideal cardiovascular health by states. B, Age-standardized percentage of population with 0 to 2 cardiovascular health metrics by states. C, Age-standardized mean score of cardiovascular health metrics by states.

BRFSS indicates Behavioral Risk Factor Surveillance System.

Reprinted from Fang et al²⁸ with permission. Copyright © 2013, American Heart Association, Inc.

• The most up-to-date data on national prevalence of ideal, intermediate, and poor levels of each of the 7 cardiovascular health metrics are shown for adolescents and teens (Chart 2-2) and for adults (Chart 2-3).

  

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  Chart 2-3

  Prevalence (unadjusted) estimates of poor, intermediate, and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals, among US adults aged 20 to 49 and ≥50 years

  *Healthy Diet Score reflects 2011 to 2012 NHANES.

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2013 to 2014.

• For most metrics, the prevalence of ideal levels of health behaviors and health factors is higher in US children than in US adults. The main exceptions are diet and PA, for which the prevalence of ideal levels in children are similar to (for PA) or worse (for diet) than in adults.

• Among US children (Chart 2-2), the prevalence (unadjusted) of ideal levels of cardiovascular health behaviors and factors currently varies from <1% for the healthy diet pattern (ie, <1 in 100 US children meets at least 4 of the 5 dietary components or a corresponding AHA diet score of at least 80) to >80% for the smoking, BP, and fasting glucose metrics.

• Among US adults (Chart 2-3), the age-standardized prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from <1% for having a healthy diet pattern to up to 77% for never having smoked or being a former smoker who has quit for >12 months.

• Age-standardized and age-specific prevalence estimates for ideal cardiovascular health and for ideal levels of each of its components are shown for 2011 to 2012 and 2013 to 2014 in Table 2-2. NHANES 2011 to 2012 data are used for some of the statistics that require nutritional data because 2013 to 2014 data have not been released. The prevalence of ideal levels across 7 health factors and health behaviors generally was lower with age, with much lower prevalence among older versus younger age groups. The exception was diet, for which prevalence of ideal levels was highest in older adults.

• Chart 2-4 displays the prevalence estimates for the population of US children (12–19 years of age) meeting different numbers of criteria for ideal cardiovascular health (out of 7 possible) in 2011 to 2012.

  

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  Chart 2-4

  Proportion (unadjusted) of US children aged 12 to 19 years meeting different numbers of criteria for ideal cardiovascular health, overall and by sex

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2011 to 2012.

  • Few US children (≈5%) meet only 0, 1, or 2 criteria for ideal cardiovascular health.

  • Approximately half of US children (54%) meet 3 or 4 criteria for ideal cardiovascular health, and ≈41% meet 5 or 6 criteria (mostly 5 criteria).

  • <1% of children meet all 7 criteria for ideal cardiovascular health.

• Charts 2-5 and 2-6 display the age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal cardiovascular health (out of 7 possible) in 2011 to 2012, overall and stratified by age, sex, and race.

  

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  Chart 2-5

  Age-standardized prevalence estimates of US adults aged ≥20 years meeting different numbers of criteria for ideal cardiovascular health, overall and by age and sex subgroups

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2011 to 2012.

  

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  Chart 2-6

  Age-standardized prevalence estimates of US adults aged ≥20 years meeting different numbers of criteria for ideal cardiovascular health, overall and in selected race subgroups

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2011 to 2012.

  • Approximately 3% of US adults have 0 of the 7 criteria at ideal levels, and another 15% meet only 1 of 7 criteria. This is much worse than among children.

  • Most US adults (≈65%) have 2, 3, or 4 criteria at ideal cardiovascular health, with ≈20% adults within each of these categories.

  • Approximately 13% of US adults have 5 criteria, 5% have 6 criteria, and virtually 0% have 7 criteria at ideal levels.

  • Presence of ideal cardiovascular health is both age and sex related (Chart 2-5). Younger adults are more likely to meet greater numbers of ideal metrics than are older adults. More than 60% of Americans >60 years of age have ≤2 metrics at ideal levels. At any age, females tend to have more metrics at ideal levels than do males.

  • Presence of ideal cardiovascular health also varies by race (Chart 2-6). Blacks and Hispanics tend to have fewer metrics at ideal levels than whites or other races. Approximately 6 in 10 white adults and 7 in 10 black or Hispanic adults have no more than 3 of 7 metrics at ideal levels.

• Chart 2-7 displays the age-standardized percentages of US adults and percentages of children who have ≥5 of the metrics (of 7 possible) at ideal levels.

  

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  Chart 2-7

  Prevalence of meeting ≥5 criteria for ideal cardiovascular health among US adults aged ≥20 years (age-standardized) and US children aged 12 to 19 years, overall and by sex

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2007 to 2008 and 2011 to 2012.

  • Approximately 41% of US children 12 to 19 years of age have ≥5 metrics at ideal levels, with similar prevalence in boys (42%) as in girls (41%).

  • In comparison, only 17% of US adults have ≥5 metrics at ideal levels, with lower prevalence in males (13%) than in females (21%).

  • All populations have improved since baseline year 2007 to 2008.

• Chart 2-8 displays the age-standardized percentages of US adults and percentages of children by race/ethnicity who have ≥5 of the metrics (of 7 possible) at ideal levels.

  

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  Chart 2-8

  Prevalence of meeting ≥5 criteria for ideal cardiovascular health among US adults aged ≥20 years (age standardized) and US children aged 12 to 19 years, by race/ethnicity

  NH indicates non-Hispanic.

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2011 to 2012.

  • In both children and adults, non-Hispanic Asians tend to have higher prevalence of having ≥5 metrics at ideal levels than other race/ethnic groups.

  • Approximately 4.7 in 10 non-Hispanic Asian children, 4.4 in 10 non-Hispanic white children, 3.5 in 10 non-Hispanic black children, and 3.7 in 10 Hispanic children have ≥5 metrics at ideal levels.

  • By comparison, among adults, ≈2.6 in 10 non-Hispanic Asians, 1.8 in 10 non-Hispanic whites, 1.3 in 10 Hispanics, and 1 in 10 non-Hispanic blacks have ≥5 metrics at ideal levels.

• Chart 2-9 displays the age-standardized percentages of US adults who meet different numbers of criteria for both poor and ideal cardiovascular health. Meeting the AHA 2020 Strategic Impact Goals is predicated on reducing the relative percentage of those with poor levels while increasing the relative percentage of those with ideal levels for each of the 7 metrics.

  

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  Chart 2-9

  Age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal and poor cardiovascular health, for each of the 7 metrics of cardiovascular health in the American Heart Association 2020 goals, among US adults aged ≥20 years

  Source: National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES) 2011 to 2012.

  • Approximately 92% of US adults have ≥1 metric at poor levels.

  • Approximately 34% of US adults have ≥3 metrics at poor levels.

  • Few US adults (2.5%) have ≥5 metrics at poor levels.

  • More US adults have 4 to 6 ideal metrics than 4 to 6 poor metrics.

• Using data from the BRFSS, Fang et al²⁸ estimated the prevalence of ideal cardiovascular health by state (all 7 metrics at ideal level), which ranged from 1.2% (Oklahoma) to 6.9% (District of Columbia). Southern states tended to have higher percentages of poor cardiovascular health, lower percentages of ideal cardiovascular health, and lower mean cardiovascular health scores than New England and Western states (Chart 2-10).

Cardiovascular Health: Trends Over Time

(See Charts 2-11, 2-12, 2-13)

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Chart 2-11

Trends in prevalence (unadjusted) of meeting criteria for ideal cardiovascular health for each of the 7 metrics among US children aged 12 to 19 years

*Because of changes in the physical activity questionnaire between different cycles of the National Health and Nutrition Examination Survey (NHANES), trends over time for this indicator should be interpreted with caution, and statistical comparisons should not be attempted.

Data for the Healthy Diet Score, based on a 2-day average intake, was only available for the 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010 and 2011 to 2012 NHANES cycles at the time of this analysis.

Source: National Center for Health Statistics, NHANES 1999 to 2000 through 2013 to 2014.

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Chart 2-12

Age-standardized trends in prevalence of meeting criteria for ideal cardiovascular health for each of the 7 metrics among US adults aged ≥20 years

*Because of changes in the physical activity questionnaire between different cycles of the National Health and Nutrition Examination Survey (NHANES), trends over time for this indicator should be interpreted with caution, and statis-tical comparisons should not be attempted.

Data for the Healthy Diet Score, based on a 2-day average intake, was only available for the 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010 and 2011 to 2012 NHANES cycles at the time of this analysis.

Source: National Center for Health Statistics, NHANES 1999 to 2000 through 2013 to 2014.

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Chart 2-13

Prevalence of ideal, intermediate, and poor cardiovascular health metrics in 2006 (American Heart Association 2020 Impact Goals baseline year) and 2020 projections assuming current trends continue

The 2020 targets for each cardiovascular health metric assume a 20% relative increase in ideal cardiovascular health prevalence metrics and a 20% relative decrease in poor cardiovascular health prevalence metrics for males and females.

Reprinted from Huffman et al²⁹ with permission. Copyright © 2012, American Heart Association, Inc.

• The trends over the past decade in each of the 7 cardiovascular health metrics (for diet, trends from 1999–2000 through 2013–2014) are shown in Chart 2-11 (for children 12–19 years of age) and Chart 2-12 (for adults ≥20 years of age).

  • The prevalence of both children and adults meeting the dietary goals improved between 2003 to 2004 and 2011 to 2012. The prevalence of ideal levels of diet (AHA diet score >80) increased from 0.2% to 0.6% in children and from 0.7% to 1.5% in adults (Chapter 5, Charts 5-2 and 5-3). The prevalence of intermediate levels of diet (AHA diet score 40–79) increased from 30.6% to 44.7% in children and from 49.0% to 57.5% in adults. These improvements were largely attributable to increased whole grain consumption and decreased sugar-sweetened beverage consumption in both children and adults, as well as small, nonsignificant trends in increased fruits and vegetables (Chapter 5, Charts 5-4 and 5-5). No major trends were evident in either children or adults meeting the target for consumption of fish or sodium.

    

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    Chart 5-2

    Healthy diet targets in children (5–19 years old) by survey year: NHANES 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010, and 2011 to 2012

    Components of poor, intermediate, and ideal diet are defined in Table 5-1. Percentages based on the alternative scoring ranges described in Table 5-1.

    NHANES indicates National Health and Nutrition Examination Survey.

    Sources: My Life Check: Life’s Simple 7¹; Lloyd-Jones et al²; Rehm et al.³

    

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    Chart 5-3

    Healthy diet targets in adults (≥20 years of age) by survey year: NHANES 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010, and 2011 to 2012

    Components of poor, intermediate, and ideal diet are defined in Table 5-1. Percentages based on the alternative scoring ranges described in Table 5-1.

    NHANES indicates National Health and Nutrition Examination Survey.

    Sources: My Life Check: Life’s Simple 7¹; Lloyd-Jones et al²; Rehm et al.³

    

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    Chart 5-4

    Trends in AHA-defined healthy diet score components for children (5–19 years old) by survey year: NHANES 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010, and 2011 to 2012

    Unscaled dietary score (maximum=50). Mean healthy diet score components based on the alternative scoring ranges described in Table 5-1.

    AHA indicates American Heart Association; max., maximum; and NHANES, National Health and Nutrition Examination Survey.

    Sources: My Life Check: Life’s Simple 7¹; Lloyd-Jones et al²; Rehm et al.³

    

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    Chart 5-5

    Trends in AHA healthy diet score components for adults (≥20 years of age) by survey year: NHANES 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010, and 2011 to 2012

    Unscaled dietary score (maximum=50). Mean healthy diet score components based on the scoring ranges described in Table 5-1.

    AHA indicates American Heart Association; and NHANES, National Health and Nutrition Examination Survey.

    Sources: My Life Check: Life’s Simple 7¹; Lloyd-Jones et al²; Rehm et al.³

  • Fewer children over time are meeting the ideal BMI metric, whereas more are meeting the ideal smoking and TC metrics. Other metrics do not show consistent trends over time in children.

  • More adults over time are meeting the smoking metric, whereas fewer are meeting the BMI and glucose metrics. Trends for other metrics are not evident over time in adults.

• On the basis of NHANES data from 1988 to 2008, if current trends continue, estimated cardiovascular health is projected to improve by 6% between 2010 and 2020, short of the AHA’s goal of 20% improvement (Chart 2-13).²⁹ On the basis of current trends among individual metrics, anticipated declines in prevalence of smoking, high cholesterol, and HBP (in males) would be offset by substantial increases in the prevalence of obesity and DM and smaller changes in ideal dietary patterns or PA.²⁹

• On the basis of these projections in cardiovascular health factors and behaviors, CHD deaths are projected to decrease by 30% between 2010 and 2020 because of projected improvements in TC, SBP, smoking, and PA (≈167 000 fewer deaths), offset by increases in DM and BMI (≈24 000 more deaths).³⁰

CVD Mortality

(See Charts 2-14 through 2-16)

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Chart 2-14

US age-standardized death rates* from cardiovascular diseases, 2000 to 2014

CHD indicates coronary heart disease; and CVD, cardiovascular disease.

*Directly standardized to the age distribution of the 2000 US standard population. †Total CVD: International Classification of Diseases, 10th Revision (ICD-10) I00 to I99, Q20 to Q28. §Stroke (all cerebrovascular disease): ICD-10 I60 to I69. ¶CHD: ICD-10 I20 to I25. **Other CVD: ICD-10 I00 to I15, I26 to I51, I70 to I78, I80 to I89, I95 to I99.

Source: Centers for Disease Control and Prevention, National Vital Health Statistics System.³¹

• In 2014, the age-standardized death rate attributable to all CVD in the US population was 220.8 per 100 000, down 14.9% from 259.4 per 100 000 in 2007 (baseline data for the 2020 Impact Goals on CVD and stroke mortality)³¹ (Chart 2-14).

• The age-standardized death rate in 2014 attributable to stroke was 36.5 per 100 000, a decrease of 16.1% from 2007. The death rate attributable to CHD in 2014 was 98.8 per 100 000, a reduction of 23.5% from 2007. The rate for other CVDs was 84.6 per 100 000 in 2014, similar to the rate in 2007³¹ (Chart 2-14).

• Between 2007 and 2013, CVD and stroke death rates decreased 12.5% and 16.1% respectively in non-Hispanic whites; 16.5% and 20.2% in non-Hispanic blacks; 18.1% and 17.3% in Hispanics; 15.0% and 19.6% in non-Hispanic Asian and Pacific Islanders; and 11.3% and 22.5% in non-Hispanic American Indian or Alaska Natives³¹ (Charts 2-15 and 2-16).

  

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  Chart 2-15

  US age-standardized death rates* from cardiovascular disease by race/ethnicity, 2000 to 2014

  NH indicates non-Hispanic.

  *Directly standardized to the age distribution of the 2000 US standard population. Total CVD: International Classification of Diseases, 10th Revision (ICD-10) I00 to I99, Q20 to Q28.

  Source: Centers for Disease Control and Prevention, National Vital Statistics System.³¹

Prevalence

Incidence

• According to 2014 NSDUH⁴:

  • Approximately 2.16 million people ≥12 years of age smoked cigarettes for the first time within the past 12 months, down from 2.3 million in 2012. The 2012 estimate averages out to ≈5700 new cigarette smokers every day. Half of new smokers aged ≥12 in 2013 (38.7%) were <12 to 17 years of age when they first smoked cigarettes (NSDUH); 93.3% were 12 to 25 years of age. Unfortunately, the number of new smokers did not change significantly between 2013 and 2014.

  • The number of new smokers 12 to 17 years of age (83 800) was down from 2002 (1.3 million); new smokers 18 to 25 years of age increased from ≈600 000 in 2002 to 1.181 million in 2014.

• In the NHIS, between 2005 and 2014:

  • Among people 12 to 49 years of age who had started smoking within the past 12 months, the average age of first cigarette use was 17.8 years, the same as in 2012.

Mortality

• In 2010, tobacco smoking was the second-leading risk factor for death in the United States, after dietary risks.¹⁴

• Smoking was responsible for >480 000 premature deaths in the United States annually from 2005 to 2009 among those ≥35 years of age. Furthermore, almost one third of deaths of CHD are attributable to smoking and secondhand smoke exposure.⁷

• If current smoking trends continue, 5.6 million US children will die prematurely during adulthood of smoking.⁷

• From 2005 to 2009, smoking during pregnancy resulted in an estimated 970 infant deaths annually.⁷

• Each year from 2005 to 2009, an estimated 41 000 US deaths were attributable to exposure to secondhand smoke among those ≥35 years of age.⁷

• In 2009, smoking was estimated to cause 3.3 million years of potential life lost for males and 2.2 million years for females, excluding deaths attributable to smoking-attributable residential fires and adult deaths attributable to secondhand smoke.⁷

• Recent analysis found that in addition to the known risk of death attributable to CVD and stroke that is related to smoking, the risk of mortality attributable to hypertensive HD and hypertensive renal disease is related to smoking.¹⁵

• On average, male smokers die 13.2 years earlier than male nonsmokers, and female smokers die 14.5 years earlier than female nonsmokers.¹

• Overall mortality among US smokers is 3 times higher than that for never-smokers.¹⁶

• Increased CVD mortality risks persist for older (≥60 years old) smokers as well. A recent meta-analysis comparing CVD risks in 503 905 cohort participants ≥60 years of age reported an HR for cardiovascular mortality of 2.07 (95% CI, 1.82 to 2.36) compared with never smokers and 1.37 (95% CI, 1.25 to 1.49) compared with former smokers.¹⁷

• In a sample of Native Americans (Strong Heart Study), among whom the prevalence of tobacco use is highest in the United States, the PAR for total mortality was 18.4% for males and 10.9% for females.¹⁸

• Since the first report on the dangers of smoking was issued by the US Surgeon General in 1964, tobacco control efforts have contributed to a reduction of 8 million premature smoking-attributable deaths.¹⁹

Cardiovascular Health Impact

• A 2010 report of the US Surgeon General on how tobacco causes disease summarized an extensive body of literature on smoking and CVD and the mechanisms through which smoking is thought to cause CVD.²⁰ There is a sharp increase in CVD risk with low levels of exposure to cigarette smoke, including secondhand smoke, and a less rapid further increase in risk as the number of cigarettes per day increases. Similar health risks for CHD events are reported with regular cigar smoking as well.²¹

• Smoking is an independent risk factor for CHD and appears to have a multiplicative effect with the other major risk factors for CHD: high serum levels of lipids, untreated hypertension, and DM.²⁰

• Cigarette smoking and other traditional CHD risk factors may have a synergistic interaction in HIV-positive individuals.²²

• A meta-analysis of 75 cohort studies (≈2.4 million individuals) demonstrated a 25% greater risk for CHD in female smokers when compared with male smokers (RR, 1.25; 95% CI, 1.12 to 1.39).²³

• Cigarette smoking is an independent risk factor for both ischemic stroke and SAH and has a synergistic effect on other stroke risk factors such as SBP²⁴ and oral contraceptive use.^25,26

• A meta-analysis comparing pooled data of ≈3.8 million smokers and nonsmokers found a similar risk of stroke associated with current smoking in females and males.²⁷

• Current smokers have a 2 to 4 times increased risk of stroke compared with nonsmokers or those who have quit for >10 years.^28,29

• Acute exposure to water pipe smoking is associated with a significant increase in SBP and heart rate compared with nonsmoking control subjects,³⁰ but long-term effects remain unclear. Current use of smokeless tobacco is associated with an increased risk of CVD events in cigarette nonsmokers.³¹

Cost

• Each year from 2005 to 2009, US smoking-attributable economic costs were between $289 billion and $333 billion, including $133 billion to $176 billion for direct medical care of adults and $151 billion for lost productivity related to premature death.⁷

• In the United States, cigarette smoking is associated with 9% of annual aggregated healthcare spending.³²

• In 2008, $9.94 billion was spent on marketing cigarettes in the United States.³³

• Cigarette prices in the United States have increased 283% between the early 1980s and 2011, in large part because of excise taxes on tobacco products. Higher taxes have decreased cigarette consumption, which fell from ≈30 million packs sold in 1982 to ≈14 million packs sold in 2011.³³

Smoking Prevention

• Tobacco 21 Laws increase the minimum age of sale for tobacco products from 18 to 21 years old. Such legislation would likely reduce the rates of smoking during adolescence, a time during which the majority of smokers start smoking, by limiting access, because most people who buy cigarettes for adolescents are <21 years of age. In several towns where Tobacco 21 laws have been enacted, 47% reductions in smoking prevalence among high school students have been reported.³⁴ Furthermore, the Institute of Medicine estimates that a nationwide Tobacco 21 law would result in 249 000 fewer premature deaths, 45 000 fewer lung cancer deaths, and 4.2 million fewer lost life-years among Americans born between 2010 and 2019.³⁵ As of 2016, 125 localities and the states of Hawaii and California have adopted Tobacco 21 laws, and momentum is building. A federal Tobacco 21 law was introduced to the Congress in September 2015; review and a vote are pending.

Smoking Cessation

• Smoking cessation reduces the risk of cardiovascular morbidity and mortality for smokers with and without CHD.

  • There is no convincing evidence to date that reducing the amount smoked by smoking fewer cigarettes per day reduces the risk of CVD, although in several studies a dose-response relationship has been seen among current smokers between the number of cigarettes smoked per day and CVD incidence.²⁰

• Quitting smoking at any age significantly lowers mortality from smoking-related diseases, and the risk declines more the longer the time since quitting smoking.³⁶ Cessation appears to have both short-term (weeks to months) and long-term (years) benefits for lowering CVD risk. Overall, risk appears to approach that of nonsmokers after ≈10 years of cessation.

• Smokers who quit smoking at 25 to 34 years of age gained 10 years of life compared with those who continued to smoke. Those aged 35 to 44 years gained 9 years and those aged 45 to 54 years gained 6 years of life, on average, compared with those who continued to smoke.¹⁶

• In 2010, 48.3% of adult current smokers ≥18 years of age who had a health checkup during the preceding year reported that they had been advised to quit. Smokers between 18 and 24 (31%) and 24 to 44 (44%) years of age were less likely to be advised to quit than those at older ages (57%; NHIS).³⁷

• Cessation medications (including sustained-release bupropion, varenicline, and nicotine gum, lozenge, nasal spray, and patch) are effective for helping smokers quit.³⁸

• EVITA was an RCT that examined the efficacy of varenicline versus placebo for smoking cessation among smokers who were hospitalized for ACS. At 24 weeks, rates of smoking abstinence and reduction were significantly higher among patients randomized to varenicline. Point-prevalence abstinence rates were 47.3% in the varenicline group and 32.5% in the placebo group (P=0.012; number needed to treat=6.8). Continuous abstinence rates and reduction rates (≥50% of daily cigarette consumption) were also higher in the varenicline group.³⁹

• The recently reported EAGLES trial demonstrated efficacy and safety of 12 weeks of varenicline, bupropion, or nicotine patch in motivated-to-quit smoking patients with major depressive disorder, bipolar disorder, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, social phobia, psychotic disorders including schizophrenia and schizoaffective disorders, and borderline personality disorder. Of note, these participants were all clinically stable from a psychiatric perspective and were believed not to be at high risk for self-injury.⁴⁰

• Extended use of a nicotine patch (24 weeks compared with 8 weeks) has been demonstrated to be safe and efficacious in recent randomized clinical trials.⁴¹

• An RCT demonstrated the effectiveness of individual- and group-oriented financial incentives for tobacco abstinence through at least 12 months of follow-up.⁴²

• In addition to medications, smoke-free policies, increases in tobacco prices, cessation advice from healthcare professionals, and quit-lines and other counseling have contributed to smoking cessation.³⁷

• In 2010, 52.4% of adult smokers reported having tried to quit smoking in the past year; 6.2% reported they had recently quit smoking. Of those who tried to quit smoking, 30.0% used cessation medications.³⁷

• The majority of ex-smokers report that they quit without any formal assistance.⁴³

• Mass media antismoking campaigns, such as the CDC’s Tips campaign (Tips From Former Smokers), have been shown to reduce smoking-attributable morbidity and mortality and are cost-effective.⁴⁴

• Despite states having collected $25.6 billion in 2012 from the 1998 Tobacco Master Settlement Agreement and tobacco taxes, <2% of those funds are spent on tobacco prevention and cessation programs. In addition, progress in passing and raising tobacco taxes and enacting smoke-free laws has slowed.⁴⁵

• In 2014, a major drug store chain, CVS Caremark Corporation, stopped selling tobacco products, a step that could reduce access to tobacco products and therefore encourage some smokers to quit.⁴⁶

Electronic Cigarettes

(See Chart 3-6)

• Electronic nicotine delivery systems, more commonly called electronic cigarettes or e-cigarettes, are battery-operated devices that deliver nicotine, flavors, and other chemicals to the user in an aerosol. Although e-cigarettes were introduced less than a decade ago, there are currently >450 e-cigarette brands on the market, and sales in the United States were projected to be $2 billion in 2014.⁴⁷

• Because these products have not been well studied, their risks and benefits are not fully understood, although they are thought to have a lower risk of harmful effects than conventional cigarettes. ^48,49 Specifically, the health risks from the inhaled nicotine, solvents, heavy metals, flavorings, and other chemicals in e-cigarettes are not entirely known.^7,50,51 However, a recent cross-sectional study compared the effects of electronic cigarettes versus traditional cigarettes on markers of oxidative stress and endothelial function in healthy smokers and nonsmoker adults and found that e-cigarettes appeared to have a lesser impact.⁵² Until prospective cohort studies evaluating hard clinical outcomes become available, future studies are required to examine the association of e-cigarettes and markers reflecting long-term cardiovascular damage, such as coronary artery calcium.

• In addition to uncertainty about the harmful effects to users, the risks associated with secondhand exposure to e-cigarettes have not been well studied. ^48,49,53 Moreover, there is also the potential for thirdhand exposure with e-cigarettes, which results from tobacco toxins remaining on the surfaces in areas where people have smoked. A study found that thirdhand exposure levels differed depending on the surface and the e-cigarette brand.⁵⁴

• E-cigarettes could play a beneficial role in helping smokers reduce or eliminate their conventional cigarette smoking; however, there are concerns that e-cigarettes could be a gateway to nicotine addiction and tobacco use by nonsmokers, especially teenagers, or could promote relapse among former smokers.^7,50,51

• Teenagers are increasingly trying e-cigarettes. In 2015, e-cigarettes were the most commonly used tobacco product among middle school (5.3%) and high school (16.0%) students.⁵⁵ In 2013, 3.0% of middle school students had ever tried e-cigarettes, up from 1.4% in 2011. In 2013, 11.9% of high school students had ever tried e-cigarettes, up from 4.7% in 2011⁵⁶ (Chart 3-6).

• In 2014, 18.3 million US middle and high school students were exposed to e-cigarette advertising. ⁵⁵ Among US adults during 2010 to 2013, awareness and use of e-cigarettes increased considerably, and more than one third of current cigarette smokers reported ever having used e-cigarettes.⁵⁷

• As of June 30, 2016, 46 states, Guam, and the US Virgin Islands had banned e-cigarettes sales to minors, and 8 states prohibited e-cigarette use in private worksites, restaurants, and bars.⁵⁸

• Many public health advocates are worried that e-cigarettes will reverse decades of efforts to denormalize smoking, which contributed to the decline in smoking.^7,50,51,53

• The answers to some of these questions may become clearer as the regulatory oversight of e-cigarettes becomes more defined.⁷ Currently, only e-cigarettes that are marketed for therapeutic purposes are regulated by the US Food and Drug Administration, but in April 2014, the US Food and Drug Administration proposed extending its tobacco product authorities to include e-cigarettes.⁵⁹

• In May 2016, the US Food and Drug Administration released its long-awaited final “deeming” regulations on noncigarette tobacco products, including e-cigarettes, cigars, little cigars, pipe tobacco, hookah pipes, and other tobacco products. Under this rule, e-cigarettes will be subjected to the same regulatory restriction as traditional cigarettes, including manufacture, marketing, and distribution. As a result, all e-cigarette products will need to undergo federal review to remain on the market, with the exception of products that entered the market before February 15, 2007. This action will also ban the sale of e-cigarettes to minors and require photo identification to purchase these products.⁶⁰

Secondhand Smoke

• Data from the US Surgeon General on the consequences of secondhand smoke indicate the following:

  • Nonsmokers who are exposed to secondhand smoke at home or at work increase their risk of developing CHD by 25% to 30%.²⁰

  • Short exposures to secondhand smoke can cause blood platelets to become stickier, damage the lining of blood vessels, and decrease coronary flow velocity reserves, potentially increasing the risk of an AMI.²⁰

  • Exposure to secondhand smoke increases the risk of stroke by 20% to 30%.⁷

  • Nearly 34 000 premature deaths of HD occur each year in the United States among nonsmokers.⁷

• These data are supported by a recent meta-analysis of 23 prospective and 17 case-control studies of cardiovascular risks associated with second-hand smoke exposure demonstrated 18%, 23%, 23%, and 29% increased risks for total mortality, total CVD, CHD, and stroke, respectively, in those exposed to secondhand smoke.⁶¹

• Data from the 2008 BRFSS from 11 states showed that the majority of people surveyed in each state reported having smoke-free home rules, ranging from 68.8% in West Virginia to 85.6% in Arizona.⁶²

• As of June 2016, 27 states and the District of Columbia had laws that prohibited smoking in indoor areas of worksites, restaurants, and bars; no states had such laws in 2000. As of June 2016, 9 states had no laws banning or restricting areas for smoking in private workplaces.⁶³

• In 2012, 30 of the 50 largest US cities prohibited indoor smoking in private workplaces, through either state or local ordinances.⁶⁴

• Pooled data from 17 studies in North America, Europe, and Australasia suggest that smoke-free legislation can reduce the incidence of acute coronary events by 10%.⁶⁵

• The percentage of the US nonsmoking population with serum cotinine ≥0.05 ng/mL (which indicates exposure to secondhand smoke) declined from 52.5% in 1999 to 2000 to 25.3% in 2011 to 2012, with declines occurring for both children and adults. During 2011 to 2012, the percentage of nonsmokers with detectable serum cotinine was 40.6% for those 3 to 11 years of age, 33.8% for those 12 to 19 years of age, and 21.3% for those ≥20 years of age. The percentage was also higher for non-Hispanic blacks (46.8%) than for non-Hispanic whites (21.8%) and Mexican Americans (23.9%). People living below the poverty level (43.2%) and those living in rental housing (36.8%) had higher rates of secondhand smoke exposure than their counterparts (21.1% of those living above the poverty level and 19.0% of those who owned their homes; NHANES).⁶⁶

Defining and Measuring PA

There are 4 dimensions of PA (mode or type, frequency, duration, and intensity) and 4 common domains (occupational, domestic, transportation, and leisure time). The federal guidelines specify the suggested frequency, duration, and intensity of activity. Historically, recommendations on PA for health purposes have focused on leisure-time activity. However, because all domains of PA could have an impact on health, and because an increase in 1 domain may sometimes be compensated for by a decrease in another domain, ideally data will be collected on all dimensions and domains of PA.

There are 2 broad categories of methods to assess PA: (1) subjective methods that use questionnaires and diaries/logs and (2) objective methods that use wearable monitors (pedometers, accelerometers, etc). Studies that compare the findings between subjective methods (respondent reported) and objective methods (such as wearable monitors, like pedometers or accelerometers) have found that there is marked discordance between self-reported and measured PA, with respondents often overstating their PA, especially the intensity.^4,5 The majority of studies linking inactivity/PA to cardiovascular outcomes obtain PA data from respondent reports, which may overestimate the amount or intensity of activity.

Another consideration in the measurement of PA is that surveys often ask only about leisure-time PA. PA also may come from occupational, domestic, and transportation responsibilities. People who get a lot of PA from these other responsibilities may be less like to engage in leisure-time PA, and yet they may meet the federal PA guidelines, but they may be less likely to be identified as meeting the guidelines.

Chronic physical inactivity contributes to poor levels of cardiorespiratory (or aerobic) fitness, which is a stronger predictor of adverse cardiometabolic and cardiovascular outcomes than traditional risk factors. Although both PA and cardiorespiratory fitness are inversely related to the risk of CVD and other clinical outcomes, they are distinct measures in the assessment of CVD risk.⁶ PA is a behavior that can potentially improve cardiorespiratory fitness. Although many studies have shown that increasing the amount and quality of PA can improve cardiorespiratory fitness, other factors can contribute, such as a genetic predisposition to perform aerobic exercise.⁷ Because cardiorespiratory fitness is directly measured and reflects both participation in PA and the state of physiological systems affecting performance, the relationship between cardiorespiratory fitness and clinical outcomes is stronger than the relationship of PA to a series of clinical outcomes.⁶ Unlike health behaviors such as PA and risk factors that are tracked by federally funded programs, there are no national data on cardiorespiratory fitness; the development of a national cardiorespiratory fitness registry has been proposed.⁶ Such additional data on the cardiorespiratory fitness levels of Americans may give a fuller and more accurate picture of physical fitness levels.⁶

Prevalence

Mortality

• According to the WHO, physical inactivity is the fourth-leading risk factor for global death, responsible for 3.2 million deaths annually, including an estimated 670 000 premature deaths (people aged <60 years) and 30% of IHD burden.¹⁵

• The Global Burden of Disease investigators estimated that worldwide, physical inactivity contributed to 2.2 million deaths in 2013.¹⁶

• Adults ≥40 years of age who participated in moderate to vigorous PA once a week or more had a lower mortality risk than those who were inactive. Furthermore, older adults who engaged in moderate to vigorous PA ≥5 times per week had a significantly lower mortality risk than those who participated in a lower frequency of PA.¹⁷

• A meta-analysis of 9 cohort studies, representing 122 417 patients, found that as little as 15 minutes of daily moderate to vigorous PA reduced all-cause mortality in adults ≥60 years of age. This protective effect of PA was dose dependent; the most rapid reduction in mortality per minute of added PA was for those at the lowest levels of PA. These findings suggest that older adults can benefit from PA time far below the amount recommended by the federal guidelines.¹⁸

• A study of US adults that linked a large, nationally representative sample to death records found that meeting the aerobic PA guidelines reduced all-cause mortality, with an HR of 0.64, after adjustment for potential confounding factors.¹⁹

• A pooled study of >600 000 participants found that even low levels of leisure-time PA (up to 75 minutes of brisk walking per week) were associated with reduced risk of mortality compared with participants with no PA. If this is a causal relationship, this low level of PA would confer a 1.8-year gain in life expectancy after age 40 years compared with no PA. For participants meeting the PA guidelines, the gain in life expectancy was 3.4 years over those with no PA.²⁰

• With television watching as a sedentary activity, 2 hours of television per day is associated with an RR for type 2 DM of 1.20 (95% CI, 1.14–1.27), an RR for fatal or nonfatal CVD of 1.15 (95% CI, 1.06–1.23), and an RR for all-cause mortality of 1.13 (95% CI, 1.07–1.18). The risk for all-cause mortality further increases with >3 hours of television daily.²¹

• Adherence to PA guidelines for both aerobic and muscle-strengthening activities is associated with 27% lower all-cause mortality among adults without existing chronic conditions such as DM, cancer, MI, angina, CVD, stroke, or respiratory diseases and with 46% lower mortality among people with chronic comorbidities.²²

• In a 20-year study of older male veterans, an inverse, graded, and independent association between impaired exercise capacity and all-cause mortality risk was found. For each increase of 1 metabolic equivalent task in exercise capacity, mortality risk was 12% lower (HR, 0.88; 95% CI, 0.86–0.90). Unfit individuals who improved their fitness status had a 35% lower mortality risk (HR, 0.65; 95% CI, 0.46–0.93) than those who remained unfit.²³

• In the Cooper Center Longitudinal Study, an analysis conducted on 16 533 participants revealed that across all risk factor strata, the presence of low cardiorespiratory fitness was associated with a greater risk of CVD death over a mean follow-up of 28 years.²⁴

• In the Southern Community Cohort Study of 63 308 individuals (with a large proportion of black adults) followed up for >6.4 years, more time spent being sedentary (>12 h/d versus <5.76 h/d) was associated with a 20% to 25% increased risk of all-cause mortality in blacks and whites. Both PA (beneficial) and sedentary time (detrimental) were associated with mortality risk.²⁵

• In a study involving 55 137 adults followed up over an average of 15 years, running even 5 to 10 min/d and at slow speeds (<6 mph) was associated with a markedly reduced risk of death attributable to all causes and CVD.²⁶

• A population-based cohort in New South Wales, Australia, of 204 542 adults followed up for an average of 6.5 years evaluated the relationship of PA to mortality risk. It found that compared with those who reported no moderate to vigorous PA, the adjusted HRs for all-cause mortality were 0.66 for those reporting 10–149 min/wk, 0.53 for those reporting 150–299 min/wk, and 0.46 for those reporting ≥300 min/wk of activity.²⁷

• An analysis of pooled data from 6 studies in the National Cancer Institute Cohort Consortium involving 661 137 males and females followed up for an average of 14.2 years revealed that compared with individuals reporting no leisure-time PA, an inverse dose-response relationship was observed between level of leisure-time PA (HR=0.80 for less than the recommended minimum of the PA guidelines, HR=0.69 for 1 to 2 times the recommended minimum, and HR=0.63 for 2 to 3 times the minimum) and mortality, with the upper threshold for mortality benefit occurring at 3 to 5 times the PA recommendations (HR, 0.61). Furthermore, there was no evidence of harm associated with performing ≥10 times the recommended minimum (HR, 0.69). Thus, meeting the 2008 minimum PA guidelines for Americans through either moderate- or vigorous-intensity activities was essentially associated with a nearly optimal reduction in mortality risk. This study supports the view that although healthcare professionals should encourage inactive people to become physically active, they should not discourage adults who are already very active at levels far above those recommended by the guidelines.²⁸

• A study that prospectively assessed the association of continuous inactivity and of changes in sitting time for 2 years with subsequent long-term all-cause mortality found that compared with people who remained consistently sedentary, the HRs for mortality were 0.91 in those who were newly sedentary, 0.86 in formerly sedentary individuals, and 0.75 in those who remained consistently non-sedentary. Thus, participants who reduced their sitting time over 2 years experienced a reduction in mortality.²⁹

• A meta-analysis of 17 eligible studies on PA in patients with DM revealed that the highest PA category in each study was associated with a lower RR (0.61) for all-cause mortality and CVD (0.71) than the lowest PA category. Although more PA was associated with larger reductions in future all-cause mortality and CVD, in patients with DM, any amount of habitual PA was better than inactivity.³⁰

Costs

• The economic consequences of physical inactivity are substantial. Using data derived primarily from WHO publications and data warehouses, one study estimated the economic costs of physical inactivity account for 1.5% to 3.0% of total direct healthcare expenditures in developed countries such as the United States.³¹

• A study of Australian females aged 50 to 55 years found that healthcare costs were 26% higher in sedentary females than in moderately active females. Costs included visits to general practitioners, medical specialists, and outpatient pathology and radiology services.³²

• A study of American adults reported that inadequate levels of aerobic PA (after adjusting for BMI) were associated with an estimated 11.1% of aggregate healthcare expenditures (including expenditures for inpatient, outpatient, ED, office-based, dental, vision, home health, prescription drug, and other services).³³

• An evaluation of healthcare costs based on the cardiovascular risk factor profile (including ≥30 minutes of moderate to vigorous PA ≥5 times per week) found that among adults aged ≥40 years with CVD, the highest marginal expenditures ($2853) were for those not meeting the PA guidelines. Healthcare costs included hospitalizations, prescribed medications, outpatient visits (hospital outpatient visits and office-based visits), ED visits, and other expenditures (dental visits, vision aid, home health care, and other medical supplies).³⁴

Secular Trends

Cardiovascular Health Impact

Primordial and Primary Prevention

• Community-level interventions have been shown to be effective in promoting increased PA.

• The US Surgeon General has introduced Step It Up!, a Call to Action to Promote Walking and Walkable Communities in recognition of the importance of PA.⁵⁷ There are roles for the following:

  • Communities: Communities can encourage walking with street design that includes side-walks, improved street lighting, and landscaping design that reduces traffic speed to improve pedestrian safety.

  • Schools: Schools can provide opportunities for PA through physical education, recess, after-school activity programs, and PA breaks. Despite these recommendations, only one-quarter of students participate in daily PA classes (see Structured Activity Participation).

  • Worksites: Worksites can offer access to onsite exercise facilities or employer-subsidized off-site exercise facilities to encourage PA among employees.

  • Community-wide campaigns: Such campaigns include a variety of strategies, such as media coverage, risk factor screening and education, community events, and policy or environmental changes.

• A systematic review of population-based interventions to encourage PA found that improving biking trails, distributing pedometers, and school-based PA were most cost-effective.⁵⁸

• Educating the public on the recommended PA guidelines may increase adherence. In a study examining awareness of current US PA guidelines, only 33% of respondents had direct knowledge of the recommended dosage of PA (ie, frequency/duration).⁵⁹

• Interventions and community strategies to increase PA have been shown to be cost-effective in terms of reducing medical costs⁶⁰:

  • Nearly $3 in medical cost savings is realized for every $1 invested in building bike and walking trails.

  • Incremental cost and incremental effectiveness ratios range from $14 000 to $69 000 per QALY gained from interventions such as pedometer or walking programs compared with no intervention, especially in high-risk groups.

Secondary Prevention

• In a retrospective cohort study of 2086 patients (39% females, 56% white) who underwent clinical treadmill testing and had a first MI during follow-up (mean of 11 years), a higher baseline level of cardiorespiratory fitness was independently associated with a decreased risk of short-term mortality (28 days after a first MI).⁶¹

• PA improves inflammatory markers in people with existing stable CHD. After a 6-week training session, CRP levels declined by 23.7% (P<0.001), and plasma vascular cell adhesion molecule-1 levels declined by 10.23% (P<0.05); there was no difference in leukocyte count or levels of intercellular adhesion molecule-1.⁶²

• In a randomized trial of patients with PAD, supervised treadmill exercise training and lower-extremity resistance training were each associated with significant improvements in functional performance and quality of life compared with a usual-care control group. Exercise training also improved brachial artery FMD, whereas resistance training was associated with better stair-climbing ability than control.⁶³

• On the basis of a meta-analysis of 34 RCTs, exercise-based cardiac rehabilitation after MI was associated with lower rates of reinfarction, cardiac mortality, and overall mortality.⁶⁴

• The benefit of intense exercise training for cardiac rehabilitation in people with HF was tested in a trial of 27 patients with stable, medically treated HF. Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in LVEF and decreases in pro-BNP (40%), LV end-diastolic volume (18%), and LV end-systolic volume (25%) compared with control and endurance-training groups.⁶⁵

• Exercise training in patients with HF with preserved EF was associated with improved exercise capacity and favorable changes in diastolic function.⁶⁶

Prevalence and Trends in the AHA 2020 Healthy Diet Metrics

(See Table 5-1 and Charts 5-1 through 5-5)

• The AHA’s 2020 Impact Goals include a new priority of improving cardiovascular health.¹ The definition of cardiovascular health includes a healthy diet pattern, characterized by 5 primary and 3 secondary metrics (Table 5-1), that should be consumed within the context of a healthy dietary pattern that is appropriate in energy balance and consistent with a DASH-type eating plan.¹

• The AHA scoring system for ideal, intermediate, and poor diet patterns uses a binary-based scoring system, which awards 1 point for meeting the ideal target for each metric and 0 points otherwise.² For better consistency with other dietary pattern scores such as DASH, an alternative continuous scoring system has been developed to measure small improvements over time towards the AHA ideal target levels (Table 5-1). The dietary targets remain the same, and progress toward each of these targets is assessed by use of a more granular range of 1 to 10 (rather than 0 to 1).

• On the basis of the alternative scoring system, between 2003 to 2004 and 2011 to 2012 in the United States, the mean AHA healthy diet score improved in both children and adults (Chart 5-1). The prevalence of an ideal healthy diet score (>80) increased from 0.2% to 0.6% in children (Chart 5-2) and from 0.7% to 1.5% in adults (Chart 5-3). The prevalence of an intermediate healthy diet score (40–79) increased from 30.6% to 44.7% in children and from 49.0% to 57.5% in adults.³

  • These improvements were largely attributable to increased whole grain consumption and decreased sugar-sweetened beverage consumption in both children and adults (Charts 5-4 and 5-5).³ No major trends were evident in adults in progress toward the targets for consumption of fish or sodium.

• Other significant changes between 1999 and 2012 included national increases in nuts, seeds, and legumes (0.26 servings/d) and whole fruit (0.15 servings/d) and decreases in 100% fruit juice (0.11 servings/d) and white potatoes (0.07 servings/d (95% CI).³

• Although AHA healthy diet scores tended to improve in all race/ethnicity, income, and education levels, many disparities present in earlier years widened over time, with generally smaller improvements seen in minority groups and those with lower income or education.³ For example, among Americans with the highest family income (income-to-poverty ratio ≥3.0), the proportion with a poor diet decreased from 50.5% to 35.7%, whereas among those with lowest family income (income-to-poverty ratio <1.3), the proportion with a poor diet decreased from 67.8% to only 60.6%.

Dietary Habits in the United States: Current Intakes

Impact on US Mortality

• One report used consistent and comparable risk assessment methods and nationally representative data to estimate the impact of all major modifiable risk factors on mortality and morbidity in the United States in 1990 and in 2010.⁵ Among 17 leading risk factors in the United States in 2010, suboptimal dietary habits were the leading cause of both mortality and DALYs lost. In 2010, a total of 678 000 deaths of all causes were attributable to suboptimal diet.

• A previous investigation reported the estimated mortality effects of several specific dietary risk factors in 2005 in the United States. High dietary salt consumption was estimated to be responsible for 102 000 annual deaths, low dietary omega-3 fatty acids for 84 000 annual deaths, high dietary trans fatty acids for 82 000 annual deaths, and low consumption of fruits and vegetables for 55 000 annual deaths.⁶

Cost

(See Chart 5-7)

The US Department of Agriculture forecast that the Consumer Price Index for all food would increase 3.0% to 4.0% in 2013 as retailers continued to pass on higher commodity and energy costs to consumers in the form of higher retail prices. The Consumer Price Index for food increased 3.7% in 2011. Prices for foods eaten at home increased 4.8% in 2011, whereas prices for foods eaten away from home increased by 1.9%.⁷

• A meta-analysis of price comparisons of healthier versus unhealthier diet patterns found that the healthiest diet patterns cost, on average, approximately $1.50 more per person per day to consume.⁸

• In an assessment of snacks served at YMCA afterschool programs from 2006 to 2008, healthful snacks were ≈50% more expensive ($0.26 per snack) than less healthful snacks.⁹ Higher snack costs were driven by serving fruit juice compared with water; serving refined grains without trans fat compared with refined grains with trans fats; and serving fruit and canned or frozen vegetables. Serving fresh vegetables (mostly carrots or celery) or whole grains did not alter price.

• As a proportion of income, food has become less expensive over time in the United States. As a share of personal disposable income, average (mean) total food expenditures by families and individuals have decreased from 22.3% (1949) to 18.1% (1961) to 14.9% (1981) to 11.3% (2011). For any given year, the share of disposable income spent on food is inversely proportional to absolute income. The share increases as absolute income levels decline.⁷

• The proportion of total US food expenditures for meals outside the home, as a share of total food dollars, increased from 27% in 1961 to 40% in 1981 to 49% in 2011.¹⁰

• The proportion of sales of meals and snacks from fast-food restaurants, compared with total meals and snacks away from home, increased from 5% in 1958 to 29% in 1982 to 36% in 2011.⁷

• Among 153 forms of fruits and vegetables priced with 2008 Nielsen Homescan data, price and calorie per portion of 20 fruits and vegetables were compared with 20 common snack foods, such as cookies, chips, pastries, and crackers. Average price per portion of fruits and vegetables was 31 cents, with an average of 57 calories per portion, compared with 33 cents and 183 calories per portion for snack foods.⁷

• An overview of the costs of various strategies for primary prevention of CVD determined that the estimated costs per year of life gained were between $9800 and $18 000 for statin therapy, $1500 for nurse screening and lifestyle advice, $500 to $1250 for smoking cessation, and $20 to $900 for population-based healthy eating.¹¹

• Each year, more than $33 billion in medical costs and $9 billion in lost productivity resulting from HD, cancer, stroke, and DM are attributed to poor nutrition.^12–15

• Two separate cost-effectiveness analyses estimated that population reductions in dietary salt would not only be cost-effective, but actually cost-saving. ^16,17 In 1 analysis, a 1.2-g/d reduction in dietary sodium was projected to reduce US annual cases of incident CHD by 60 000 to 120 000, stroke by 32 000 to 66 000, and total mortality by 44 000 to 92 000.¹⁷ If accomplished through a regulatory intervention, estimated savings in healthcare costs would be $10 to $24 billion annually. ¹⁷ Such an intervention would be more cost-effective than using medications to lower BP in all people with hypertension.

Secular Trends